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Closed-angle glaucoma

закрытоугольная глаукома

In Ukraine, glaucoma remains the leader among conditions that lead to visual impairment. Closed-angle glaucoma is less common among this pathology, but it occurs at an earlier age, from 30-35 years old.

To figure out what closed-angle glaucoma is, it is enough to have an idea of the anatomical nuances of the eye structure. It produces a special fluid that feeds the internal structures. Through a drainage system in the anterior eye angle, this fluid drains to the scleral veins. Microcirculation and outflow can be impaired if the anterior eye angle is blocked by the structures of the visual organ — the lens and the iris.

Fluid accumulates, provoking high intraocular pressure (IOP) being the main sign of glaucoma, including closed-angle glaucoma. In the first stages of the pathological process, it does not make itself felt, so it is crucial to determine it in advance at a doctor’s appointment.

Eximer Ophthalmology Clinic performs early diagnosis of closed-angle glaucoma with innovative and professional equipment, as well as selects an individual treatment plan for each particular case.

Causes of closed-angle glaucoma

The main cause of the disease is overlapping of the angle of the eye chamber, caused by anatomical features. It is an individual structure of the visual organs that leads to the disease. The large crystalline lens, thickened iris, small chamber, and shortened eyeball.

Other factors affect the disease progression as well. If closed-angle glaucoma occurs, the causes may be as follows:

  • Concomitant pathologies such as cataracts, diseases of the endocrine system, trauma to the eye.
  • The pathology often occurs in representatives of East Asian countries.
  • Congenital abnormalities of the visual organs of genetic nature. The angle of the anterior chamber of the eye overlaps due to abnormalities that occur in the 3rd trimester of pregnancy.

Symptoms of closed-angle glaucoma

The condition may remain unnoticed for a long time, evolving into a chronic disease, or it can manifest itself in an acute attack.

If closed-angle glaucoma is suspected, the symptoms of the chronic process may be as follows:

  • Discomfort in the eye area;
  • Blurred vision or decreased vision;
  • A narrow visual field;
  • Severe headache, which decreases during sleep and when lying down;
  • Iridescent halos in front of the eyes, especially when looking at a distant light source;
  • Intermittent “lightning flashes” in front of the eyes.

An acute attack leads to irreversible vision loss; thus, it is extremely dangerous. Within several hours, the IOP exceeds 40 mm Hg (the normal value is 18-22 mm Hg). In this case, you should immediately seek medical attention and reduce the IOP.

Types and features of closed-angle glaucoma

There are three types of this condition.

Primary closed-angle glaucoma

The primary form of the disease occurs as an independent process. Three degrees of pathology are distinguished concerning IOP values according to Maklakov:

  • А — IOP values are practically within the normal range, not exceeding 27 mm Hg;
  • В — IOP fluctuates within 28-32 mm Hg;
  • С — pressure values are above 32 mm Hg.

Closed-angle glaucoma 1A means that the process is just developing and the intraocular pressure can still be controlled. If diagnosed at this stage, the condition can be treated with a favorable prognosis.

Primary closed-angle glaucoma is also classified into subtypes:

  • With a functional pupillary block. The angle of the chamber overlaps the iris root, which is the most common form.
  • Creeping glaucoma. The angle of the chamber is reduced due to the fusion of the iris root with the anterior wall of the angle.
  • Flat iris. It is observed when the iris root is thick.
  • Vitreolens block. A very rare form that occurs due to anatomical nuances such as a small eye and a large lens.

Secondary closed-angle glaucoma

Secondary glaucoma is a condition that develops with other processes:

  • It is caused by inflammation of the vascular meshwork in the ocular membrane (uveitis).
  • It occurs after diseases that affect the eye lens, including hyphema, lens subluxation, and cataracts.
  • Developing the disease is possible after undergoing eye surgery, as well as after trauma to the organ.
  • Medication-induced. It occurs during long-term treatment with hormones, corticosteroids, alpha-chymotrypsin.
  • Neovascular. It occurs rarely, almost not subject to correction. Vessels of an abnormal nature are formed, which prevent the passage of fluid.

Acute closed-angle glaucoma

As mentioned above, in an acute attack, IOP increases sharply, which is manifested by:

  • Severe, sharp pain in the affected eye;
  • Sudden vision loss;
  • Colored halos around the light source;
  • Headache with nausea and vomiting;
  • Severe eye redness.

An acute attack can be confused with other pathologies. If such symptoms occur, it is vital to call an ambulance immediately.

Stages of closed-angle glaucoma

Glaucoma is broadly classified and includes several parameters. Four stages are distinguished regarding nerve damage:

Stage Description
I (start of process) visual fields are still within the normal range, but small changes are already observed. there is a depression in the optic disc (excavation).
II (development) angle-closure glaucoma of the second degree makes changes in the field of view, reduces its boundaries. the paracentral section is narrowed by 10 degrees or more. deepening in the optic nerve head is clearly expressed.
III (the process has gone far) the field boundary is narrowed to 15 degrees from the fixation point. pathological changes in the optic nerve (excavation) reach the edges.
IV (final) total excavation, complete loss of vision. it is possible to maintain a small lumen of the field of view and reaction to light.

Diagnosis

To diagnose glaucoma, the hydrodynamics of the eye and visual function are studied in detail by special methods. Eximer Ophthalmology Clinic employs state-of-the-art equipment to examine the eye ground and other structures of the eye as accurately as possible.

If closed-angle glaucoma is suspected, the clinic’s diagnostics follows the recommendations of the International Council of Ophthalmology:

  • Study of the visual field with computer perimeter;
  • IOP measurement with a tonometer;
  • Determination of the lens thickness, and measurement of the anterior chamber depth using a pachymeter;
  • Examination of the anterior chamber angle by gonioscopy.

Additional diagnostic methods are also used to examine the optic nerve, lens, and iris.

Treatment of closed-angle glaucoma

The treatment is determined by the cause of angle closure and the individual risks for a particular patient. According to international guidelines for the treatment of closed-angle glaucoma, therapy may also depend on the stage of the disease.

Stage Symptoms Limits of IOP reduction Treatment option
Initial Persistent angle closure, optic nerve damage, visual field loss More than 25% Drug treatment, lens extraction and artificial intraocular lens (IOL) implantation
2 and 3 More than 25-50% Medical treatment and/or trabeculectomy. removal of a cataract and implantation iol is possible. cyclophotocoagulation (or cryotherapy)
Terminal Blindness, possible pain More than 25-50%, in the presence of pain Drug treatment, cyclophotocoagulation (or cryotherapy)

Medications

Medications cannot restore the full fluid balance inside the eye. They can only maintain it. Medications can reduce the fluid production and improve fluid outflow. Drug treatment requires regular check-ups and visits to an ophthalmologist.

Laser treatment

Laser treatment is considered to be an attenuated, effective, and modern method. As for Ukraine, this treatment is performed at Eximer Ophthalmology Clinic in Kyiv.

Here we employ several techniques:

  • Laser iridectomy. The laser affects the iris, forming an opening to allow normal fluid discharge. This opens the anterior chamber angle, so iridectomy is indicated in the earliest stages as prevention when the angle has not yet closed, but there is such a risk.
  • Laser trabeculoplasty. It normalizes the IOP by applying a special laser to the trabecular meshwork.
    This intervention takes several minutes, and the patient can return to his/her usual way of life the next day.

Surgical treatment

Surgical treatment of glaucoma is one of the most demanded methods. At Eximer Ophthalmology Clinic, only the leading modern solutions in ophthalmic surgery are used:

  1. Non-penetrating deep sclerectomy (NPDS). The corneal membrane is surgically thinned, and fluid outflow is restored naturally. During the surgery, the patient may have collagen drains implanted to prevent tissue scarring. Such systems also allow prolonging the effect of surgical intervention.
  2. Ex-Press fluid filtration device implantation. This method has been used in glaucoma surgery for more than a decade. The Ex-Press device is installed as an additional drain. It is implanted under the sclera flap and fixed to drain the fluid. The device allows avoiding high rates of trauma and complications after the intervention, as well as reducing the number of scheduled visits to the ophthalmologist in the future. It is considered one of the safest methods.
  3. Ahmed Valve implantation. The system controls the IOP level by providing a connection between the chamber of the eye and the supratentorial space.
  4. IOL implantation is an additional manipulation. Cataract phacoemulsification is often indicated for glaucoma. A large crystalline lens can interfere with intraocular fluid drainage and provoke glaucoma, so it is removed.

Contraindications

If closed-angle glaucoma is diagnosed, contraindications to surgery are as follows:

  • Other severe abnormalities of the visual organs;
  • Risk of decreased visual acuity exceeds the possibility of a positive postoperative effect.

Several tests must be performed before the intervention, and in the case of diabetes mellitus, a consultation with an endocrinologist is a must.

Closed-angle glaucoma — prohibitions and recommendations

When a patient is diagnosed with closed-angle glaucoma, he/she should reconsider his/her lifestyle and habits. This condition can be controlled with medications at the doctor’s discretion. At the same time, some measures assist in halting the progression.

Restrictions and activities to avoid:

  • Alcohol and tobacco, which negatively affect blood circulation.
  • Reading and watching TV in a poorly lit room (due to severe eye strain).
  • Lifting heavy weights and exercising with the head below knee level.
  • Clothing that disrupts blood flow to the head and neck.
  • Drinking over 1.5 liters of fluid per day.
  • Procedures associated with temperature fluctuations such as saunas, bathhouses, hot baths.
  • Certain medications such as hormonal contraceptives, antidepressants, and vasoconstrictive eye drops.

To detect glaucoma in time, it is recommended to visit an ophthalmologist once a year, or once every 6 months if there have been cases in your family. Do not take any medication without a doctor’s prescription, never self-diagnose and self-treat!

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